Healthcare Provider Details

I. General information

NPI: 1285863340
Provider Name (Legal Business Name): WALTER A HENDERSON JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2009
Last Update Date: 01/04/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 S. SUMMIT DR.
HOLTS SUMMIT MO
65043
US

IV. Provider business mailing address

320 S. SUMMIT DR.
HOLTS SUMMIT MO
65043
US

V. Phone/Fax

Practice location:
  • Phone: 573-896-5128
  • Fax:
Mailing address:
  • Phone: 573-896-5128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number013112
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: